Weight loss and financial incentives: a flawed scheme?

Financial incentives shape our daily routines – for example, if we do not work, we do not get paid – but to what extent should they shape our health choices and/or those of others? Asserting our autonomy entails behaving according to our individual preferences and values, free of both influence and coercion, and when Ashcroft (2011) sought to reconcile financial incentives with the concept of autonomy, he concluded that ‘they [financial incentives] may be in general or in specific instances paternalistic, coercive, involve bribery, or undermine the agency of the person.’ It seems reasonable to suppose that financial incentives may risk undermining the moral integrity of decision-making.

But what does the evidence show? When Korean mathematicians Lee et al (2021) devised an epidemic model to investigate the theoretical role of financial incentives to see how they might usefully address the COVID-19 pandemic, they found that ‘the larger the incentive budget is, the faster the epidemic will end’, but also included this subtle qualifier: ‘it is assumed that there is no moral hazard for rewards …’. In the real world, however, such an assumption might evince unwarranted optimism. For example, citing studies of negative outcomes of financial incentives – including reduced patient motivation and adverse effects on the trust that is intrinsic to a doctor-patient relationship – Hagoel et al (2013) reported that laypersons in an Israeli population they questioned ‘found administering incentives in exchange for colorectal cancer screening inappropriate on rational and moral grounds’; in a literature review by Tambor et al (2016), they found that ‘qualitative studies indicate limited trust of older people in the use of explicit financial incentives for health promotion and prevention’; a UK study by Judah et al (2018) concluded: ‘Financial incentives, particularly lottery-based incentives, attract fewer patients to diabetic eye screening than standard invites in this population’; and the title of a study by Moller et al (2012) – ‘Financial Motivation Undermines Maintenance in an Intensive Diet and Activity Intervention’ – summarises their findings.